eMedicine Specialties > Urology > Stones

Bladder Stones

Author: Joseph Basler, MD, PhD, Professor, Department of Urology, University of Texas Health Science Center at San Antonio; Chief, Section of Urology, Audie Murphy Veterans Affairs Hospital
Coauthor(s): Christopher H Cantrill, MD, Resident Physician, Department of Urology, University of Texas Health Science Center, San Antonio; Jennifer J Lucas, MD, Staff Physician, Department of Urology, University of Texas Health Science Center at San Antonio; Aldo Ghobriel, MD, Staff Physician, Department of Surgery, Division of Urology, University of Texas Health Sciences Center at San Antonio
Contributor Information and Disclosures

Updated: Nov 17, 2009

Introduction

Bladder calculi are an uncommon cause of illness in most Western countries, but they result in specific symptoms and are a significant source of discomfort. This article discusses the diagnosis and current management techniques for vesical calculus disease.

For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center and Procedures Center. Also, see eMedicine's patient education articles Cystoscopy, Intravenous Pyelogram, and Blood in the Urine.

History of the Procedure

Bladder stones have been treated both medically and surgically for many centuries. The oldest bladder stone discovered dates back to 4800 BC and was found by archeologists in Egypt around the turn of the 20th century.¹ The first literary references to bladder stones date back to a time as early as, or earlier than, the time of Hippocrates.² More than 23 centuries ago, Hippocrates warned that, "To cut through the bladder is lethal," and part of the Hippocratic oath includes, "I will not cut for stone, even for the patients in whom the disease is manifest; I will leave this operation to be performed by practitioners." His admonition to young physicians was to leave this highly risky and complicated procedure to the purveyors (ie, the lithotomists) of what could only be described as an art.¹

Famous historical figures who developed vesical calculi include King Leopold I of Belgium, Napoleon Bonaparte, Emperor Napoleon III, Peter the Great, Louis XIV, George IV, Oliver Cromwell, Benjamin Franklin, the philosopher Bacon, the scientist Newton, the physicians Harvey and Boerhaave, and the anatomist Scarpa.¹

Operations to remove bladder stones via the perineum were performed by Hindus, Greeks, Romans, and Arabs. Ammonius (200 BC), Celsus (first century), and the Hindu surgeon Susruta were among the first to write about perineal lithotomy to treat bladder calculi.¹ They wrote excellent and sometimes detailed descriptions of the surgery, including preoperative and postoperative care and management.² In the 1500s, Pierre Franco introduced suprapubic lithotomy.³ Frère Jacques Beaulieu developed the lateral approach to perineal vesicolithotomy in the late 1600s. An itinerant lithotomist with little anatomic understanding but impeccable character, Beaulieu performed the often-lethal procedure in France through the early 1700s. He is remembered by the urologic community as the subject of an old French nursery rhyme, although some have suggested that it was really written as a satirical mockery of the Jacobinic monks whose order was popular in France at the time.⁴

In an attempt to avoid incisions, another form of surgical treatment, transurethral lithotrity, became more common in the early 1800s. Lithotrity was developed through creative applications of everyday tools. The Egyptian physicians were known to pass large wooden or cartilage cannulas through the urethra, followed by manual aspiration of the stones from the bladder. A popular technique of the 1700s involved passage of a long nail via the urethra; the nail was then struck with a blacksmith’s hammer, fracturing the stone.

Although many other creative and colorful transurethral instruments were developed, technological advancement in the modern era came in the form of the fenestrated lithotrite. This device allowed stones to be grasped and crushed so their fragments could be evacuated from the bladder via glass or metal suction bottles. Sir Philip Crampton was the first to introduce the manual crushing concept in Dublin (circa 1834). However, litholapaxy was not firmly established until Henry J. Bigelow, the famous professor of surgery at Harvard, performed (1876) and popularized (1878) the procedure.¹ The mechanical crushing of stones remained popular through the 1960s and 1970s, although it was fraught with complications when performed by inexperienced urologists.⁵

In the 1950s, endoscopic electrohydraulic lithotripsy (EHL) was first performed in the Soviet Union. Over the next 4 decades, multiple other modalities have been developed and allow safe transurethral or percutaneous stone ablation.⁶

Problem

Vesical calculi refer to the presence of stones or calcified materials in the bladder (or bladder substitute that functions as a urinary reservoir). These stones are usually associated with urinary stasis, but they can form in healthy individuals without evidence of anatomic defects, strictures, infections, or foreign bodies. The presence of upper urinary tract calculi is not necessarily a predisposition to the formation of bladder stones.

Frequency

The incidence of primary bladder calculi in the United States and Western Europe has been steadily and significantly declining since the 19th century because of improved diet, nutrition, and infection control. In these countries, vesical calculi affect adults, with a steadily declining frequency in children. In the Western hemisphere, vesical calculi primarily affect men who are usually older than 50 years and have associated bladder outlet obstruction. However, bladder calculi remain common in less-developed countries and areas such as Thailand, Burma, Indonesia, the Middle East, and North Africa. Although the prevalence of bladder calculi is declining in these populations, it remains a disease that affects children, among whom the disease is far more common in boys than in girls.⁶

In 1977, Van Reen published a symposium on idiopathic urinary bladder stone disease.⁷ Unfortunately, no definitive worldwide data accurately reflect the frequency of bladder calculi. This is mostly because of poor hospital records in developing regions of the world. Despite several studies in countries with a high incidence of the disease, the reporting is not uniform.

Etiology

Bladder outlet obstruction remains the most common cause of bladder calculi in adults. Prostatic enlargement, elevation of the bladder neck, and high postvoid residual urine volume cause stasis, which leads to crystal nucleation and accretion. This ultimately results in overt calculi. In addition, patients who have static urine and develop urinary tract infections are more likely to form bladder calculi. In a study of patients with spinal cord injuries (newly acquired neurogenic bladders) who were monitored for more than 8 years, 36% developed bladder calculi. More recent reports indicate that, because of better care of patients with injured spinal cords, this rate has dropped to less than 10%.

Bladder inflammation secondary to external beam radiation or schistosomiasis can also predispose to vesical calculi.⁸ The dystrophic calcifications that develop radiotherapy-related bladder and prostate damage might serve as a nidus for stone formation. Congenital or acquired vesical diverticula may serve a reservoir of urinary stasis, leading to stone formation. Other rare anatomic abnormalities that have been implicated as contributors to stasis and stone formation include sliding inguinal hernias containing the urinary bladder.⁹

Multiple underlying risk factors predispose to bladder stones in pediatric patients who undergo bladder augmentation. Mathoera et al (2000) described risk factors for stone formation in 89 pediatric patients who had undergone bladder augmentation and presented with bladder calculi. Cloacal malformations, vaginal reconstructions, ureteral reimplantations, and bladder neck surgery were all associated with higher risk for stone formation. Preventive antibiotic therapy for recurrent infections decreased the amount of struvite stone formation but yielded no statistically significant reduction in overall stone formation.¹⁰

Other etiologic factors for bladder stone formation include foreign bodies in the bladder that act as a nidus for stone formation. These are subclassified into iatrogenic and noniatrogenic bodies. The first group includes suture material, shattered Foley catheter balloons, eggshell calcifications that form on a catheter balloon, staples, ureteral stents, migrating contraceptive devices, erosions of surgical implants, and prostatic urethral stents.^{11,12,13,14,15} Stones on suture material may have an early presentation if sutures were originally placed within the bladder lumen or may have a delayed presentation if they are caused by erosion through the bladder wall.¹⁶ Noniatrogenic causes include objects placed into the bladder by the patients for recreational and various other reasons.¹⁷

Metabolic abnormalities are not a significant cause of stone formation in patients with urinary diversions. In this group of patients, the stones are primarily composed of calcium and struvite. In rare cases, medications (eg, viral protease inhibitors) may be the source for bladder calculus formation.¹⁸

In general, if an otherwise healthy person in the United States or Europe is found to have a bladder stone, a complete urological evaluation must be undertaken to find a cause for urinary stasis. Examples include benign prostatic hyperplasia, urethral stricture, neurogenic bladder, diverticula, and congenital anomalies such as ureterocele and bladder neck contracture. In females, examples include an incontinence repair that is too tight, cystoceles, and bladder diverticula.¹⁹

Pathophysiology

Most vesical calculi are formed de novo within the bladder, but some may initially have formed within the kidneys as a dissociated Randall plaque or on a sloughed papilla and subsequently passed into the bladder, where additional deposition of crystals cause the stone to grow. However, most renal stones that are small enough to pass through the ureters are also small enough to pass through a normally functioning bladder and unobstructed urethra. In older men with bladder stones composed of uric acid, the stone most likely formed in the bladder. Stones composed of calcium oxalate are usually initially formed in the kidney.

The most common type of vesical stone in adults is composed of uric acid (>50%). Less frequently, bladder calculi are composed of calcium oxalate, calcium phosphate, ammonium urate, cysteine, or magnesium ammonium phosphate (when associated with infection).^20,21 Interestingly, patients with uric acid bladder calculi rarely ever have a documented history of gout or hyperuricemia. In many cases, the core is composed of one chemical, while layers of different chemicals form around it.

Pediatric stones are composed mainly of ammonium acid urate, calcium oxalate, or an impure mixture of ammonium acid urate and calcium oxalate with calcium phosphate.²² The common link among endemic areas relates to feeding infants human breast milk and polished rice. These foods are low in phosphorus, ultimately leading to high ammonia excretion. These children also usually have a high intake of oxalate-rich vegetables (increased oxalate crystalluria) and animal protein (low dietary citrate).^23,7,22 Bladder stones in patients with spinal cord injuries are often composed of struvite or calcium phosphate.

Vesical calculi may be single or multiple, especially in the presence of bladder diverticula. Vesical calculi can be small or large enough to occupy the entire bladder. Their physical features range from soft to extremely hard and from having smooth-faceted surfaces to jagged spiculated surfaces, the latter termed "jack" stones based on their resemblance to the metal objects in the children's game Jacks (see Image 5). In general, most vesical calculi are mobile within the bladder, although some stones are fixed when they form on a suture, on the intravesical portion of a papillary tumor, or on retained stents.

In regions where vesical lithiasis is endemic among children, stone formation is more common among boys younger than 11 years, more common among people from low socioeconomic backgrounds, not usually associated with renal calculi, and relatively less likely to reoccur after treatment (when compared with upper tract calculi).²⁴

Presentation

The presentation of vesical calculi varies from completely asymptomatic to symptoms of suprapubic pain, dysuria, intermittency, frequency, hesitancy, nocturia, and urinary retention.²¹ Parents of children with vesical calculi may notice priapism and occasional enuresis.⁸

Other common signs include terminal gross hematuria and sudden termination of voiding with some degree of associated pain referred to the tip of the penis, scrotum, perineum, back, or hip. The discomfort may be dull or sharp and is often aggravated by sudden movements and exercise. Assuming a supine, prone, or lateral head-down position may alleviate the pain initiated by the stone impacting the bladder neck by causing it to roll back into the bladder. Less specific signs of vesical calculi include microscopic or gross hematuria, pyuria, bacteriuria, crystalluria, and urine cultures that demonstrate urea-splitting organisms.

A history of prior pelvic surgery should be sought in all patients, especially when synthetic materials were implanted.²⁵

Common physical examination findings include suprapubic tenderness, fullness, and, occasionally, a palpable distended bladder if the patient is in acute urinary retention. Associated findings include cystoceles in women, stomal stenosis (if the patient had undergone prior urinary diversion), and neurological deficits in patients with neurogenic bladder.

Historically, bladder calculi were diagnosed based on transurethral passage of van Buren sounds. The contact of the van Buren sounds with the stones causes transmission of a clicking noise or vibration, which confirms the presence of the stone. Because of advancements in cystoscopy, this maneuver is rarely used today. Currently, abdominopelvic planar radiography is used to easily identify radio-opaque stones. However, adult calculi, which are composed predominantly of uric acid, are radiolucent and, unless coated with calcium, are more difficult to visualize on radiographs. Cystoscopy, noncontrast CT scanning, and ultrasonography are common diagnostic methods used to confirm the presence of bladder calculi.⁸

Indications

Because a bladder stone is in itself a sign of an underlying problem, removal of the stone and treatment of the underlying abnormality are nearly always indicated. Management of the underlying cause of stone formation (eg, bladder outlet obstruction, infections, foreign body, diet) has been integral to preventing recurrence. Recent literature describes treatment of bladder calculi without relieving outlet obstruction, but the follow-up period was not long enough to warrant this as general practice.²⁶

Relevant Anatomy

In men, the main anatomical problem that leads to vesical obstruction is prostatic enlargement. The prostate forms a ringlike growth around the vesical neck and, when hypertrophic, can significantly impede the flow of urine. Stasis due to this blockage is responsible for the deposition of layer upon layer of new stone material.

In women, voiding dysfunction and urinary stasis can occur but are less commonly associated with calculi. Typical anatomic findings include cystoceles, enteroceles, or findings of prior urethral surgery, all of which contribute to elevated residuals. With rare exceptions, any foreign body that cannot escape the bladder is calcified and eventually forms a stone.

Contraindications

The only contraindication to bladder stone removal would be existence of the stone in a medically unstable or near-terminal asymptomatic patient.

In general, most vesical calculi procedures are performed via endoscopy. However, when the stone is too large or too hard or if the patient's urethra is too small (eg, in children) or surgically altered, complicating access to the bladder, the open or percutaneous suprapubic surgical approach is preferable.

Relative contraindications exist to certain types of bladder stone ablative techniques. Electrohydraulic lithotripsy (EHL) should be used with great caution in patients with small-capacity bladders and those with cardiac-pacing or defibrillation devices. Percutaneous lithotripsy may be more hazardous in patients who have undergone prior lower abdominal surgery or prior pelvic surgery or who have small-capacity noncompliant bladders.

Pregnancy is a relative contraindication to some forms of lithotripsy (eg, extracorporeal shock-wave lithotripsy [ESWL], EHL, mechanical lithotrity), but the benefits of eliminating a source of infection, retention, or pain with other modalities (eg, holmium laser, lithoclast), as well as a potential complicator of vaginal delivery if stones are large, may outweigh the risk of intervention.²⁷

Otherwise, the usual contraindications to any type of surgery also apply here.

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